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Clinical Observations of SI

This document appears to be an assessment form for evaluating sensory integration in children. It contains 8 sections to test various reflexes and postures including crossing the midline, protective extension, prone extension, supine flexion, asymmetrical and symmetrical tonic neck reflexes. The tester observes and records the child's performance on each task, noting whether their behavior is normal, deficient, or shows other abnormalities which could indicate issues with sensory integration. The assessment provides a standardized way to evaluate a child's motor skills and reflexes as they relate to sensory processing.

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Isti Nisa
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3K views2 pages

Clinical Observations of SI

This document appears to be an assessment form for evaluating sensory integration in children. It contains 8 sections to test various reflexes and postures including crossing the midline, protective extension, prone extension, supine flexion, asymmetrical and symmetrical tonic neck reflexes. The tester observes and records the child's performance on each task, noting whether their behavior is normal, deficient, or shows other abnormalities which could indicate issues with sensory integration. The assessment provides a standardized way to evaluate a child's motor skills and reflexes as they relate to sensory processing.

Uploaded by

Isti Nisa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Clinical Observations of Sensory Integration

Adapted from A. Jean Ayres, 1972, 1975. Revised K. Boling 2001


Made available by Parent-Child Services Group, Inc., Knoxville, TN

Name: _______________________________ Dominance: R L Mix (Hand)

Age: _______ Date of Test: ______________ R L Mix (Foot)

R L Mix (Eye)

I Crossing Midline (Child imitates a variety of positions that require crossing midline.)
(Child touches moving pencil with R, L, B hands.)

Right Left Both Simultaneously


Normal Normal Normal
Deficient Deficient Deficient

II Nystagmus (Rotate/spin child while sitting with head at 45º angle for 10 rotations in 20
seconds to the right, stop and time duration. Repeat to the left.)

Right
___ Normal excursions and duration
___ Slightly reduced excursions/duration (4-8 seconds)
___ Absent or greatly reduced excursions/duration (0-4 seconds)

Left
___ Normal excursions and duration
___ Slightly reduced excursions/duration (4-8 seconds)
___ Absent or greatly reduced excursions/duration (0-4 seconds)

III Co-Contraction (Can test on swing with quick stop/go movements or Grab therapist
thumbs and say “Don’t let me push or pull you.” Same with neck.)

Neck Shoulder Elbow Wrist


Normal ____ ____ ____ ____
Deficient ____ ____ ____ ____

IV Protective Extension (Test prone over therapy ball or sitting. Also in tall kneeling.)

Normal ____
Deficient ____

V Prone Extension Posture (TLR) (Child assumes airplane position on mat.)

____ a) Holds 25-30 seconds with moderate exertion.


____ b) Holds 25-30 seconds with great exertion.
____ c) Unable, or holds 0-19 seconds

IMC(6)-0411/01
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VI Supine Flexion Posture (TLR) (Child assumes fetal position on back.)

____ a) Holds 25-30 seconds with moderate exertion.


____ b) Holds 25-30 seconds with great exertion.
____ c) Unable, or holds 0-19 seconds

VII Asymmetrical Tonic Neck Reflex (ATNR) (Child assumes quadraped position, turn
child’s head to R then L.)

Right
___ a) Loss of balance
___ b) Elbow flexion on skull side
___ c) Internal rotation at shoulder face side
___ d) Finger spreading/curling
___ e) Can assume without reaction in limbs

Left
___ a) Loss of balance
___ b) Elbow flexion on skull side
___ c) Internal rotation at shoulder face side
___ d) Finger spreading/curling
___ e) Can assume without reaction in limbs

VIII Symmetrical Tonic Neck Reflex (STNR) (Child assumes quadraped position, flex and
extend child’s head.)

___ a) No change in joint flexion or extension


___ b) Definite change in joint flexion or extension
___ c) Child sits on feet
___ d) Child’s trunk sags

IMC(6)-0411/01
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